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<br /> <br /> A P P END I X A <br /> SAMPLE <br /> INllJSTRIAL PREIRFAThENT PRŒRAM <br /> WASTf.'Wl\TER SURVEY Fœ INIUSIRIAL USERS <br /> APPLICATIOO Fœ WL\STEWI\TER DISCHARGE PmMIT <br /> SOCfIOO A - GENERAl.. INF1:mt\TIOO <br /> A.1 Company name, mailing address, and phone number: <br /> <br /> Zip Code: Phone No.: <br /> A.2 Address of production or manufacturing facility. (If same as above, <br /> check [ J .) <br /> <br /> Zip Code: Phone No.: <br /> A.3 Name, title, phone number of person authorized to represent this firm in <br /> official dealings with the City: <br /> Name: Ti tle: <br /> Phone: <br /> A.4 Identify the type of business conducted: <br /> rum 10 SI~ING ŒFICIAL: In accordance with Title 40 of the Code of <br /> Federal Regulations, Part 403, Section 403.14, information and data <br /> provided in this questionnaire which identifies the nature and frequency <br /> of discharge shall be available to the public without restriction. <br /> Requests for confidential treatment of other information shall be <br /> governed by procedures specified in 40 CFR Part 2. <br /> 111Is is to be signed by an authorIzed official of yom' finn after adequate <br /> cOll1Jletion of this form and review of the Infonnatlon by the signing official. <br /> I have personally examined and am familiar with the Infonnation submitted in <br /> this document and attachments. Based upon my inquiry of those individuals <br /> inmediately responsible for obtaining the Information reported here. J swear <br /> that the submitted information is true. accurate and complete. I am aware <br /> there are significant penal ties for submi tting false Information. Including <br /> the possibility of fine and/or imprisonment. <br /> Date Signature of mflcial <br /> (Senl. if app]l~able) <br /> 12 <br /> City Hall. 630 East Hopkins. San Marcos, Texas 78666 . 512/353-4444 . FAX 512/396-4656 <br />